Farm Evaluation Survey Overall Instructions This Farm Evaluation Survey is prepopulated with member information you provide to the Coalition. If any information is incorrect, please indicate the correct information on the surveys. Included with this Farm Evaluation is one or more maps of your parcels (APNs) enrolled with us, depending on the number and location of parcels. Each map will have the parcel(s) outlined and include: APN Parcel Number; Field ID used for your county Pesticide Use Reporting; If no Field ID is indicated, add to the space next to each APN listed (each APN can have one or more field ID numbers. The practices recorded on the survey should correspond to the APN parcels and Field IDs shown on the map. You may subdivide a parcel into fields, assigning each field a name or number (if one is not already assigned). For example, you might have two fields of different crops in one APN so they could be identified as APN# 111-00-222; field A; APN# 111-00-222, field B, etc or any other designation used by the County Agricultural Commissioner or your own records. If all parcels/fields listed have the same practices, fill out one (1) survey for all enrolled parcels and return. Check the corresponding box(es) on the far left column to indicate the field(s) covered by the answers. If parcels/fields have different practices, make copies of the survey and fill out one (1) survey for each parcel/field with different practices. When copies are made, check the box next to the parcel(s) and Field ID(s) that the survey responses apply to. For example, if a member has 3 parcels enrolled with one crop grown (Parcel A, B and C) and he manages Parcel A and B the same, he can fill out one survey for Parcels A and B. Another survey needs to be filled out for Parcel C to record the crops or practices that differ from A and B.
Step by Step Instructions The Farm Evaluation has 5 components: Part A: Whole Farm Evaluation Part B: Specific Field Evaluation Part C: Irrigation Well Information Part D: Sediment & Erosion Control Practices Farm Map(s) Step 1: Part A: answer Questions 1 3 for all enrolled parcels. Step 2: Part B, question 1: check the parcels that the survey applies to by putting a check in the left hand box. Use the attached farm map(s) to help identify parcel numbers including Field IDs. This information corresponds to the map(s) in Part E. Fill in any missing information. Remember to fill out a survey for each of your enrolled parcels. Step 3: Part B: Answer questions 2 4 for parcels that you identified at the top of the page by checking the box next to the parcel. If parcels or fields differ in their practices, you must make a copy of the page to answer questions for parcels/fields differently. Step 4: Part C: Answer Questions 1 and 2 pertaining to irrigation well information. Give each well a unique identifier (Well ID) and list that in column 1. Use the Well ID to link the well management practices to the wells identified on the map. Also identify the location of both active and abandoned wells on the map. Transfer that identifier to the Farm Map and keep the map in your files (do not return to the Coalition). The map with well identifiers must be produced if you ever have a Regional Water Board compliance inspection. Step 5: Part D: Answer questions as you did in Part B in reference to parcels that you identify at the top of the page by checking the box next to the parcel. If parcels or fields differ in their practices you must make a copy of the page to answer questions for parcels/fields differently. Make sure you check off which parcels your answers apply to. Step 6: Review the Farm Map of your enrolled parcels (those that were checked in Step 2) and make any necessary changes to the boundaries. For example, a parcel may be enrolled and assigned to a member; however the acreage enrolled is only part of the entire parcel. If you need to update the parcel boundaries, return a copy of the updated map to the Coalition with your Farm Evaluation so the information is linked to the correct piece of land. Step 7: Sign the bottom of Part A to certify that all of the information provided is current and accurate. Return to the Coalition the signed Farm Evaluation (Part A Part D) and map(s) (Part E, if updated with parcel / field ID information).
Part A Whole Farm Evaluation Member Name: Coalition Member ID#: 1. Pesticide Application Practices (check all that apply) County Permit Followed Follow Label Restrictions Sensitive Areas Mapped Attend Trainings End of Row Shutoff When Spraying Avoid Surface Water When Spraying Reapply Rinsate to Treated Field Target Sensing Sprayer used Use Drift Control Agents 2. Who do you have help develop your crop fertility plan? (Check all that apply) Certified Crop Advisor (CCA) Pest Control Advisor (PCA) Certified Technical Service Providers by NRCS Professional Soil Scientist Professional Agronomist Monitor Wind Conditions Use Appropriate Buffer Zones Use Vegetated Drain Ditches Monitor Rain Forecasts Use PCA Recommendations Chemigation No Pesticides Applied Other Other Independently Prepared by Member UC Farm Advisor None of the above 3. Does your farm have the potential to discharge sediment to off-farm surface waters? Circle One: Yes No 4. Complete Part D on sediment and erosion control practices used on farm field(s). I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel or represented Members properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for knowingly submitting false information, including the possibility of fine and imprisonment for violations. Signature Printed Name Date Page 1
Part B Field Specific Evaluation Member Name: Coalition Member ID#: 1. Identify the Parcels and Fields that this survey applies to by checking the box in the first column below. Fill out a separate survey for parcels/fields with different practices. SW High Vulnerability is when a parcel is within an area covered by a Surface Water Management Plan. GW High Vulnerability is areas having potential for groundwater contamination. Parcel (APN) Field ID Acres Crop 2. Irrigation Practices (A secondary system could be used for crop germination, frost protection, crop cooling, etc.) Primary (check one) Drip Micro Sprinkler Furrow Sprinkler Border Strip Flood 3. Irrigation Efficiency Practices (check all that apply) Laser Leveling Use of E T in scheduling irrigations Water application scheduled to need Use of moisture probe (e.g. irrometer or tensiometer) Cover Crops Split Fertilizer Applications Soil Testing Tissue/Petiole Testing Variable Rate Applications using GPS Foliar N Application Secondary (if applicable, check one) Drip Micro Sprinkler Furrow Sprinkler Border Strip Flood Is the crop a permanent crop that will remain in production over 5 years? Do you plan and changing the irrigation practices. If yes what will be the new practice Soil Moisture Neutron Probe Pressure Bomb Other Other 4. Nitrogen Management Methods to Minimize Leaching Past the Root Zone (check all that apply) Irrigation Water N Testing Fertigation Other Other Do not apply nitrogen Page 2
Cement Pad Ground Sloped Away from Wellhead Standing water avoided around wellhead Good Housekeeping Practices* Air Gap (for nonpressurized systems Backflow Preventive / Check Valve If abandoned, year abandoned Destroyed certified by county Destroyed by licensed professional Destroyed - Unknown method Part C Irrigation Well Information If you have no irrigation wells, please check No for questions 1 and 2 1. Do you have any irrigation wells on parcels associated with this Farm Evaluation? Yes No 2. Are you aware of any known abandoned irrigation wells associated with this Farm Evaluation? Yes No 3. For abandoned wells, mark the location of these wells on the attached map(s) or your own farm map with a unique Well ID of your choice and fill in the following table. For each well, be sure to fill in the table with the Well ID that corresponds to the map and put an X next to the practices that apply to the individual well. If the well has been abandoned, indicate the year the well was abandoned (write Unk if the year is unknown; approximation is ok) and mark how the well was abandoned: Wellhead Protection Abandoned Wells Well ID *Good housekeeping practices include keeping the area surrounding the wellhead clean of trash, debris and any empty containers. Comments: Page 3
Part D Sediment & Erosion Control Practices Member Name: Coalition Member ID#: 1. Identify the Parcels and Fields that this survey applies to by checking the box in the first column below. Fill out a separate survey for parcels/fields with different practices. High Vulnerability Parcel (APN) Field ID Acres Crop SW GW 2. Irrigation Practices for Managing Sediment and Erosion (check all that apply) No irrigation drainage due to field or soil conditions. In-furrow dams are used to increase infiltration and settling out of sediment prior to entering the tail ditch. The time between pesticide applications and the next irrigation is lengthened as much as possible to mitigate runoff of sediment bound pesticide residue. Shorter irrigation runs are used with checks to manage and capture flows. PAM (polyacrylamide) used in furrow and flood irrigated fields to help bind sediment and increase infiltration. Use drip or micro-irrigation to eliminate irrigation drainage. Use of flow dissipaters to minimize erosion at discharge point. Tailwater Return System. Catchment Basin. 3. Cultural Practices for Managing Sediment and Erosion (check all that apply) No storm drainage due to field or soil conditions. Storm water is captured using field borders. Vegetated ditches are used to remove sediment as well as water soluble pesticides, phosphate fertilizers and some forms of nitrogen. Vegetative filter strips and buffers are used to capture flows. Sediment basins / holding ponds are used to settle out sediment and hydrophobic pesticides such as pyrethroids from irrigation and storm runoff. Cover crops or native vegetation are used to reduce erosion. Hedgerows or trees are used to help stabilize soils and trap sediment movement. Soil water penetration has been increased through the use of amendments, deep ripping and/or aeration. Crop rows are graded, directed and at a length that will optimize the use of rain and irrigation water. Creek banks and stream banks have been stabilized. Subsurface pipelines are used to channel runoff water. Berms are constructed at low ends of fields to capture runoff and trap sediment. Minimum tillage incorporated to minimize erosion. Field is lower than surrounding terrain. Page 4
Part E Farm Map (Keep Onsite- For Inspection Purposes Only) Update map with well locations and surface water discharge points. Legend X In Use Well Locations A Known Abandoned Well Locations DP Off Farm Surface Water Discharge Points Page 5